Description

Domenico di Bartolo, Cura e governo degli infermi (Cure of the sick), fresco in the Santa Maria della Scala, Sala del Pellegrinaio, Siena, Italy, (from the Episodes from the Life of Blessed Sorore), 1440–1441.

In the Middle Ages, hospitals were established as social institutions and remained so for centuries. They were public facilities inasmuch as they addressed a public issue: care of the poor who fell ill, providing food, shelter and succor, though hardly any treatment in the modern sense. Unless charity institutions intervened, the poor would live out their lives in misery, especially if illness prevented them from earning a living. In striking contrast with the poverty of their inhabitants, hospital buildings soon developed into wealthy, representative landmarks. Often, their sponsors endowed them with paintings, sculptures and lavishly decorated rooms for the people who managed them. Some hospitals even became patrons of the arts.[1]

The vanitas paintings, here Finis Gloriae Mundi and In Ictu Oculi, were painted by Juan de Valdés Leal for the Hospital de la Caridad in Seville, Spain, in 1670–1672.

Still, even the best endowed hospitals remained almshouses, offering no therapies that could not be found elsewhere. It was only in the late 19th century that they developed into institutions providing the best medical care available, mainly because of the introduction of Röntgen’s X-ray machine in 1897 that required patients to come to them for treatment. Whereas until then the well-to-do avoided hospitalization at all costs, they now had no alternatives. The cost of hospital treatment began to rise, and though charity often remained a valuable source of income for hospitals, patients frequently had to pay for their care. Since the poor could not afford these costs, hospitals temporarily lost their public function, a situation which prevailed in most countries until the introduction of public health systems. It can be argued that ‘hospitals fit many of the criteria of a public good. There are benefits for society from a socially cohesive, healthier and more productive population.’[2]

An 1897 set-up for taking an X-ray of the hand and diagnostics in the 1920s. X-ray machines marked the beginning of a development that would transform hospitals into hubs of medical technology.

Public healthcare systems are usually either run by the state (the Bevan model) or organized within a state-controlled framework based on health insurance policies (the Bismarck model). Why did public authorities enter this field? With the exception of semi-military institutions intended to take care of wounded or disabled soldiers — the so-called ‘invalids’ — the state showed little interest in public health before the 17th century. Cities built charitable hospitals, but they were also intended to concentrate the urban poor, preventing them from endangering public safety. What gave public authorities the idea that they needed to enter the field of public health? Historically, there have been three major reasons. First, according to the mercantilist policies dominant in the 17th and 18th centuries, in the perennial rivalry between nations, the health of the citizens had a major impact on their economic performance. The healthier the people were, the higher their productivity would be.

Second, in the latter part of the 18th century, the philosophers of the Enlightenment maintained that the provision of healthy living and working conditions should be seen as a basic human right. They held that the flaws in man’s political, economic and physical environment were the main cause of all social evils — including the uneven distribution of good health — refusing to look upon these evils as consequences of a divine order that people had to accept. These ideas, which provided a major impetus for the scientific and technological revolution that was thoroughly transforming society, had a large impact on hospital architecture. Public authorities were called upon to create institutions designed to assist nature in realizing the healing potential generally attributed to it at that time. This was the period when the view gained ground that the construction and layout of hospitals should be determined by a rational analysis of its function. Hospitals were now defined as places that should contribute to healing people and should offer patients a healthy environment. Clean air and a natural setting were seen as far more effective than medical treatment per se.

Third, a series of deadly epidemics in the 19th century drove home the point that contagious diseases tended to affect the entire urban population. They were becoming a public menace, forcing the public authorities to take action. Cholera epidemics resulted in a death toll of 14,000 in London in 1848 and 6,000 in 1866. Hamburg was hit by epidemics in 1822, 1831, 1832, 1848, 1859, 1866, 1873 and 1892. Hardly any city in Europe or the Unites States escaped the dire consequences of these plagues. Continuing the work French cartographers had begun in the 18th century, medical professionals produced maps showing which parts of cities were most affected and tracing how the disease spread. Globalization was already having an impact here; for mapping the incidence of epidemics on a global scale revealed that steam-powered ocean liners were accelerating their spread between continents.

Topographies of epidemics started to appear regularly in the 1830s and 1840s, with cholera forming a major focus of these early maps. They played an important role in identifying the source of the disease. This map by Dr. J. N. C. Rothenburg visualizes the cholera sourge of 1832 in Hamburg, Germany.

Although many hospitals were founded in the years when mercantilism dominated political thinking, the introduction of sewage systems, the supply of clean water and public housing may well have been the most effective contributions to public health and also the most expensive. These measures shaped and reshaped cities all over the world, leading one of the founders of public health, Rudolf Virchow, to maintain that medicine should be seen as a social science and politics as nothing else but medicine at a large scale.[3]

Following three outbreaks of cholera in London, UK, the civil engineer Sir Joseph Bazalgette (standing top right) developed a system of sewers for the city that was built 1859–1875, the largest and most expensive hygienic campaign of the 19th century. This ensured that sewage was no longer dumped onto the shores of the River Thames and thoroughly improved public health.

Private hospitals founded with the aim of making a profit appeared only in the late 19th century. In a fully private system, patients pay for all healthcare services themselves. Advocates of private systems argue that since health is essentially a private affair the state should not become involved in it. At the other end of the scale are fully public systems in which the state uses tax money to pay for all healthcare costs while also providing this healthcare. In practice, most countries have adopted mixed systems consisting of both private and public elements. Some require residents to obtain health insurance policies, granting subsidies for those who cannot afford them, as is the case in many Western European countries.

Public systems invariably incorporate cost control mechanisms, and they generally adopt a supply-based perspective in attempting to achieve their goals. In this model, access to public health policies can be limited to those in the lower income brackets and exclude those who can afford to pay for medical services. Sometimes, the public authorities introduce annual budget ceilings per therapy or per healthcare provider, as well as for the system as a whole.

Since the 1990s, another cost control strategy has become popular in many European states, namely the introduction of demand-driven mechanisms similar to those at work in any free market economy. Ideally, this encourages patients to act as consumers: they are expected to evaluate the effectiveness, quality and the prices of therapies offered by a potentially wide range of providers, the assumption being that this inevitably results in lower prices and, therefore, a less expensive public healthcare system. The transition to demand-driven mechanisms, however, requires complete transparency in outcomes and costs. Already in 2006 the US authorities issued an ‘Executive Order’ urging more transparency in the hope that it would spur competition. ‘Transparency of pricing will likely foster what is now absent in healthcare — a price-sensitive consumer.’[4] Patients’ perception of quality, shaped by medical outcomes and their experience during hospitalization (personal contact, empowerment, trust, safety, privacy, quality of food, behavior of nursing staff, etc.) is expected to be decisive. However, if insurance companies represent their patients and buy healthcare in bulk from providers on their behalf, as is usually done, costs are likely to be the predominant factor in the provider selection and contracting process.

Recently, lump-sum compensations per therapy (case combination model or diagnosis-treatment combinations) were introduced with the goal of achieving a uniform hospital financing system that covers medical service compensation as well as building maintenance and refurbishment within a single-case fee. A comprehensive system needs to allow for long-term building investments in the interest of improving the quality of medical care. Such strategic investments have not been possible in a system where budgets are split between building costs and the operational costs of health services. The case compensation model has also displayed shortcomings; for its focus on revenue optimization leads to a failure to set long-term goals for improving an institution’s medical services.

Whether or not the market-oriented public systems have been more effective in curbing healthcare costs and improving quality than the traditional supply-driven public systems is difficult to determine. In terms of total costs, it is hard to define what an optimum mix of private and public roles in the system would be. Apart from the costs, however, other aspects are equally relevant. Whereas the demand-driven systems are expected to serve the individual needs of the patients better, critics fear that without a coordinated and well-balanced network of healthcare facilities they may result in fragmentation. On the other hand, the supply-based systems, which allow for a higher degree of planning, are often seen as inflexible and coercive, virtually barring the patients from having a say in the way they are ‘processed’ by the system. In practice, the preferences for either system are hardly ever based on a clear assessment of the way they perform in terms of financial efficiency, patient satisfaction and the quality and effectiveness of services. One lasting achievement of the experiments with market-oriented systems, however, has been a much stronger emphasis on patients’ rights and choices than was customary only a few decades ago. This trend is now visible in supply-based systems, too, suggesting that the (assumed) advantages of market-oriented systems in terms of patient empowerment can also be integrated in those systems.[5]

Does the existence of public healthcare systems mean that their hospitals are public buildings in much the same way their medieval predecessors were, i.e. institutions that represent society’s shared values? Seemingly not, since public health is now a field marked by continuous political debate. Nevertheless, hospitals are still among the city’s most important public buildings.

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Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.